WHAT YOU NEED TO KNOW ABOUT TESTİS TESTIS TUMORS
Although testicular tumors are rare, they are the most common malignant tumor in men aged 15-35 years. It covers 1-2% of all malignant tumors in men. The overall incidence of testicular tumors is reported to be 2-3 per 100,000, but it tends to increase, albeit slowly. The incidence of testicular tumors in men during their lifetime is 0.2%. 90-95% of tumors originate from the germinal tissue. Germ cell tumors of the testis are classified as pure seminoma and nonseminomatous germ cell tumors. Seminomas are extremely sensitive to radiotherapy. Nonseminomatous germ cell tumors (NSGCT) respond particularly well to chemotherapy combinations containing platinum. In recent years, overall survival rates have been increasing with the use of advanced imaging methods and tumor markers together, changes in surgical techniques and the use of multi-drug chemotherapy protocols. While mortality rates were close to 50% in the 1950s, today this rate has fallen below 10%.
Etiology Although there is no known definite cause of testicular tumors, it is known that both congenital and acquired factors are important in the etiology of germ cell tumors. Among these factors, cryptorchidism (undescended testis) shows the strongest relationship. 7-10% of patients with testicular tumors have a history of cryptorchidism. Those with cryptorchidism, on the other hand, have a 5-15 times higher risk of developing testicular tumors. In patients with unilateral cryptorchidism and testicular tumor, 5 – 15% tumor can be seen in the contralateral testis. Seminoma is common in these patients. The risk of malignancy is highest in the intra-abdominal testis (1/20) and the lowest (1/80) in the inguinal testis. Lowering the undescended testis into the scrotum (orchiopexy) facilitates examination and tumor identification, but does not change the malignancy potential.
The use of diethylstilbestrol or estrogen-containing oral contraceptives during pregnancy increases the relative incidence of testicular tumors by 2.8%-5.3%. Acquired factors such as testicular atrophy or trauma associated with nonspecific infection or mumps infection are thought to cause malignant transformation by causing local hormonal imbalances.
The incidence of testicular tumor varies according to race, country and socioeconomic level. It is most common in Scandinavian countries, and the rarest in Africa and Asia. It is the most common solid tumor between the ages of 20-40. They also make a small peak after the age of 60 and under the age of 10. The most common histological type of seminoma is between 35 and 39 years old. Embryonal carcinoma and teratocarcinoma are most common between the ages of 25-35, and choriocarcinoma between the ages of 20-30. Although yolk sac tumors and pure benign teratomas are common in early childhood, these two histological types are seen in combination with other histological types at later ages. Malignant testicular lymphomas are more common after the age of 50. It is slightly more common in the right testis than in the left, paralleling the high incidence of cryptoorchidism.
Primary testicular tumors are approximately 2-3% bilateral-bilateral and they may occur simultaneously or in different time periods. Approximately 50% of these tumors have a history of unilateral or bilateral undescended testis. The most common bilateral testicular tumors; The germ cell tumor is seminoma. However, the most common bilateral tumor is malignant lymphoma.
All germinal cell tumors in adults should be considered malignant and treated. Spontaneous regression is very rare in this disease, and the majority of disease-related deaths occur within 3 years of diagnosis.
CLINICAL SIGNS AND SYMPTOMS OF TESTİS TUMOR
Testicular tumor patients mostly apply to the health institution with enlarged nodules or gonads. It is detected incidentally by the patient or his sexual partner. Typically, the mass is firm and not tender.
It can be easily distinguished from the epididymis. 30-40% of patients may present with mild tingling or a feeling of heaviness in the lower abdominal region, anal region, or scrotum. 10% of patients present with acute pain due to intratesticular bleeding or tumor-associated epididymitis. Due to metastatic disease, 10% patient neck mass (supraclavicular lymph node metastasis), respiratory problems such as dyspnea, anorexia and nausea-vomiting due to gastrointestinal metastases, bone pain, central and peripheral nervous system findings and even unilateral due to iliac or vena cava obstruction or bilateral lower extremity edema. Abdominal examination should be done carefully in order not to miss retroperitoneal disease. It should be kept in mind that gynecomastia may also be present in other germ cell tumors, especially in Leydig cell and Sertoli cell tumors.
Solid, firm intratesticular masses should be treated as testicular tumors until proven otherwise. Since the young population is more affected, it should be considered in the differential diagnosis. In 5-25% of patients, it can be initially misdiagnosed and treated as epididymitis.
Transscrotal ultrasonography, which is used as the basic imaging method in diagnosis, can show the presence of an intraparenchymal mass in the testis and distinguish it from other benign processes (hydrocele and epididymitis), and the other testis can be examined at the same time.
β-hCG (human chorionic gonadotropin): Its level is very low in normal adult males. Syncytiotrophpblastic tissues in some germ cell tumors produce this substance. Therefore, it can be detected in all choriocarcinomas, 40-60% in embryonal cell carcinomas and 7% in pure seminomas. They rarely exceed 2 times the normal in seminomas.
AFP (alpha fetoprotein): It is an oncofetal protein and is detected in testicular and liver tumors. Its half-life is 5-7 days. It is elevated in embryonal carcinoma, teratoma, teratocarcinoma, yolk sac tumors. They are not elevated in pure seminomas and choriocarcinomas.
LDH (Lactate dehydrogenase): LDH is a cellular enzyme that normally has 5 isoenzymes. It is found in muscle tissue, liver, kidney and brain. It is not specific for testicular tumor, but it can give an idea about the size of the tumor. It is thought that it may have a role in the follow-up of advanced seminomas and persistent nonseminomas whose tumor markers do not increase.
In conclusion, considering all stages, one or both tumor markers are elevated in 90% of nonseminomatous tumors. AFP is elevated in 50-70% of patients, and ß-hCG is elevated in 40-60% of patients. One or two of these are elevated in two-thirds of patients in stage 1. After treatment, the level of tumor markers decreases according to their half-lives. A high level or slow fall should suggest residual disease. A decrease in the level to normal does not mean that a cure has been achieved in the treatment of the disease.
Inguinal (radical) orchiectomy: The best removal of the primary lesion is achieved by clamping the spermatic cord close to the internal ring and removing the entire testis. In rare cases, exploration and frozen biopsy may be required. The scrotal approach should be avoided in terms of contamination of the inguinal lymphatics. After diagnosis, standard AC X-ray and retroperitoneal CT should be taken, considering possible metastasis areas.
Seminoma: The majority of seminomas are local and very sensitive to radiotherapy. In patients with stage 1 seminoma, follow-up is recommended after radical orchiectomy. In low-stage patients, the cure rate reaches 99%. Seminoma is also sensitive to combinations of platinum-containing chemotherapy and chemotherapy should be administered as salvage therapy after radiotherapy. In more advanced stages and in large masses that cause AFP elevation, chemotherapy should be administered first. Often, masses undergo fibrosis after chemotherapy.
Nonseminomatous germ cell tumor: Treatment alternatives in patients with stage 1 disease are follow-up, chemotherapy or RPLND. In early-stage disease, 75% of patients recover with orchiectomy alone. The major long-term complications of RPLND are ejaculation problems and infertility due to damage to the sympathetic nerve fibers. With the developed surgical techniques, it is tried to minimize the morbidity rate. Combinations of platinum-containing chemotherapy in patients with high-grade large retroperitoneal masses have revolutionized the treatment of these tumors. Surgery should be performed for the residual mass after chemotherapy.
All patients should be kept under regular follow-up. Patients should undergo careful physical examination for possible lymph node metastases and recurrent intra-abdominal mass. Complete blood count and tumor marker levels (AFP, βHCG, LDH) should be checked in laboratory studies. Chest radiogram should be taken for lung metastases and, less frequently, intra-abdominal recurrence should be investigated with abdominal CT.
ROBOTIC SURGERY FOR TESTICULAR TUMOR
The use of the da-Vinci robotic system allowed laparoscopic surgery to mimic an open bilateral approach without repositioning the patient. The robot also enables easier and more complex dissections that may allow for further resection of post-chemotherapy masses and more complete dissection behind the great vessels.
The development of the supine approach to robotic RPLND allows surgeons to better mimic open techniques and perform a complete, bilateral dissection.
Initially, during robotic RPLND, patients are placed in the lateral decubitus position to facilitate modified template dissection. This approach allows for modified template-based dissection as previously published and is sufficient for early-stage disease, but may require repositioning if a complete bilateral dissection is attempted.
The use of the robotic system (Davinci Xi) allows for wider dissection. This technique is particularly useful when performing large postchemotherapy retroperitoneal dissections. Although the complication rates between open and R-RPLND are comparable, the rate of chylous ascites is reported to be <1% versus approximately 4% in the L-RPLND and R-RPLND series, respectively. Meticulous use of surgical clips around the left renal vein and lymphatic ducts can minimize the risk of chylous ascites. Anterograde loss of ejaculation is another frequently cited complication associated with RPLND. In R-RPLND, 100% of patients can maintain ejaculatory function, at least in the primary setting with modified templates.
Reference: 1.Werntz, et al. Indications, evolving technique, and early outcomes with robotic retroperitoneal lymph node dissection, Current Opinion in Urology: September 2018 – Volume 28 – Issue 5 – p 461-468
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